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IME record summary example: an orthopedic lumbar draft

IME record summary example from a Medrecords AI orthopedic draft: 8 record sources with their page ranges, the history, a 7-line physical exam and the draft opinions for a lumbar radiculopathy evaluation. Medrecords AI drafts and cites, the examiner reviews and signs. The examinee is fictional and de-identified, and the PDF is free to download.

By Ahmed Jemaa, Co-Founder & CEO of Medrecords AI · Published 3 Nov 2026

What does an IME record summary look like?

An IME record summary lists every record the examiner reviewed, with the facility, the date span and the page range, so any statement in the report traces back to a page. In this example 8 sources cover ED, family medicine, spine, imaging, pain management, EMG, physical therapy and pharmacy records.

Source	Records	Dates	Pages
St. Mary's Medical Center	ED records	03/14/2025	p. 1 to 47
Lakeside Family Medicine	Office notes	03/2025 to 07/2026	p. 48 to 57, p. 370
OrthoWest Spine	Consult and follow-ups	04/2025 to 06/2026	p. 68 to 73, p. 156 to 364
St. Mary's Imaging	MRI lumbar	04/05/2025	Series 3, 24 slices
North Texas Pain & Spine	Notes and procedure records	05/2025 to 05/2026	p. 168 to 356
NeuroDiagnostics Center	EMG/NCS	10/15/2025	p. 268
Meridian Physical Therapy	Evaluation and notes	04/2025 to 01/2026	p. 112 to 310
Pharmacy records	Dispensing history	03/2025 to 07/2026	p. 450

History, as reported by the examinee. A 39-year-old who reports a rear-end collision on 03/14/2025, with immediate low-back pain radiating to the left leg that persisted through treatment. She denies prior lumbar complaints or treatment, reports current pain at 3 to 4 out of 10 with activity-related flares, and avoids lifting over 20 lb and prolonged sitting.

Physical examination, as drafted

The examiner enters the exam findings. The draft puts them in the order an orthopedic IME reads, and the examiner verifies each value before signature.

Finding	Result
Lumbar ROM	Flexion 60 degrees (reduced); extension 15 degrees; side bending 15/18 degrees
SLR	Left positive at 55 degrees; right negative at 80 degrees
Motor	Left EHL 4/5; left hip flexor 5/5; plantar flexion 5/5; right side 5/5
Sensory	Diminished light touch in left L5 dermatome; otherwise intact
Reflexes	Patellar and Achilles 2/4 bilaterally; no clonus; Babinski downgoing
Gait	Normal; left toe-walk mildly weak
Provocative	No sciatic tension on the right; facet loading unremarkable

Diagnoses and draft opinions

These sections hold the examiner's opinions. The draft words them from the cited records and the exam; the examiner edits, accepts or rejects each one.

Section	Draft text
Diagnoses	M51.16 L4-L5 disc herniation with radiculopathy. M54.16 Left L5 radiculopathy. S39.012 Acute lumbar strain (resolved).
Causation	Within reasonable medical probability, the L4-L5 disc herniation and left L5 radiculopathy were caused by the 03/14/2025 collision. Basis: acute symptom onset at the collision; mechanism consistent with axial loading and rotation; objective findings within 22 days; no prior lumbar treatment for 9 years.
Impairment	8% permanent impairment of the left lower extremity, reflecting the partial L5 sensory and motor deficits documented on examination. No whole-person conversion applied.
Work status and restrictions	Permanent: no lifting over 20 lb; no prolonged sitting over 45 minutes; no ladder or scaffold work; no repetitive bending.
Future care	Annual orthopedic follow-up; PRN epidural steroid injections; maintenance duloxetine; no surgery recommended at this time.

What the examiner checks before signing

The draft does the reading. The opinions stay yours. Here are 2 checks this draft invites:

The history says the examinee denies prior lumbar complaints or treatment. The causation basis says no prior lumbar treatment for 9 years. Those 2 statements do not say the same thing, and the examiner should settle which one the records support before relying on either.
The causation basis cites objective findings within 22 days. The collision is dated 03/14/2025 and the lumbar MRI 04/05/2025, which is 22 days. That one checks out against the records list.

Medrecords AI drafts and cites, the examiner reviews and signs. The software gives no opinion of its own and signs nothing.

Get the full draft

Full PDF, 2 pages The complete draft with the case overview, purpose statement and signature block. Download the PDF.

The sample page The IME report draft in the samples library, with a page 1 preview. Open the IME report sample.

A red-flag checklist The checks to run on any IME report before it goes out. Use the IME report checklist.

For the full IME workflow, see IME record review and how every line links to its source page.

IME record summary FAQs

What goes in the records-reviewed section of an IME report? Each source, the record type, the date span and the page range, plus anything without page numbers, such as an imaging series. It tells the examiner and every later reader what was reviewed and what was not.

Does Medrecords AI write the IME opinions? It drafts them from the cited records in your report structure. Causation, impairment and work status stay the examiner's opinions: you review, edit and sign. The software never signs a report.

Does it work for orthopedic IMEs? Yes. This example is an orthopedic lumbar evaluation with a disc herniation, L5 radiculopathy, an impairment rating and permanent restrictions. The records-reviewed format and page citations work the same way for other body regions.

Is this a real examinee? No. The examinee, examiner, facilities and case number are fictional and de-identified, part of a demo case built to show the format.

How long does the record review take? Medrecords AI reads about 100 pages a minute. The packet behind this example is cited up to p. 450, so the read takes about 5 minutes. Your exam and your review of the draft take as long as they need.

What does it cost? Pricing starts at 10 cents per deduplicated page, down to 5 cents with volume. You pay per page, not per case, exact duplicates are never charged, and credits never expire. First case is free on us.

Draft your next IME from the records

Bring 1 real case to a demo. Access opens within 1 business day after it, and every opinion stays yours to edit and sign. First case is free on us.

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